Tales from the Emergency Department; in which a man who wallows in nostalgia, and secretly wishes he were a Victorian KnifeMan rants about his work and what passes for a life.
He's heard it might be therapeutic...
Names have been changed to protect the innocent.
Any resemblence to parties alive or dead is purely coincidental

Sunday, April 26, 2009

A little knowledge can be a scary thing; a lot of knowledge is often little comfort, either.

Knowing the outcome before you start sometimes don't help anyone much.

When they brought the first in, she looked awful. A short history, of vomiting, was all that was offered. Seen her GP the previous day, and the same GP popped round to see how she was.

I'm not sure how often that happens anymore, but I'm full of admiration for the GP in question.

The home visit anything but homely; patient now in extremis, collapsed, flat out... The Ambos told the rest of the tale: poorly responsive, cool at the edges, papery skin dry and turgid. Feeling for a pulse at the wrist became a fruitless exercise, but a hand over the apex of the heart revealed a rapid, desperate rhythm.

She was sick, sick, sick, and I couldn't help but wonder what secrets her belly might hold. While the team forced fluid into her, squeezed hard, as if somehow this would make all the difference, I laid my hand upon her, gingerly feeling my way around the geography of the belly we know so well.

Willing it to give up its secrets...

Fluids eventually gave her back a blood pressure, and we all looked at the number, and wished we hadn't. Eminent Knifemen passed through and reassured us her belly was benign, that the evil mastermind of these signs and symptoms lay elsewhere.

We found ourselves in a sort of therapeutic no-mans-land. All agreed she was ill; all agreed the bit making her ill was someone else's bit. All agreed she needed agressive intervention; all agreed they would not do it.

I struggle to see the point in half treating someone; death comes to us all, and when we recognise that, sometimes we need to just stop

Thursday, April 23, 2009

I know I've blogged about these guys before, but I'd quite forgotten how much I love them; all the more so, considering I discovered them quite by accident, at the urging of one of my oldest and dearest friends...

Tuesday, April 21, 2009

Fair is an unusual concept in life, and yet one that we return to all too often.

For all the people we see in the ED who have stubbed their toes, who have a bit of a sore throat, who used a lump hammer to smash stuff and wonder why their shoulder aches, for all of the 'worried well', there are a dying breed who don't like to make a fuss; who feel that they are 'bothering' us at work.

Geoff was just such a man. Yesterday evening, while lugging heavy bags of compost about, he developed a pain in his chest. He described it as like having someone pull your tongue out by the root. It shot from his chest to his belly, and wa accompanied by explosive diarrhoea. He remarked on the pain to his wife, but didn't want to trouble anyone.

He took himself off to bed, where the pain got worse and worse; he became sweaty, and had trouble breathing, so much so that he got himself out of bed at 3 a.m. and spent the night in his chair. This morning he thought he ought to talk to his own doctor about it, but got worse through the day, and eventually called an ambulance.

The Ambos thought he looked a bit grey, and belted him to the ED; the Admitting Nurse also thought he looked a bit grey, and flagged him to me. He told me he wasn't too bad, tho he later admitted to pain of 8/10 severity, and marked shortness of breath.

I thought he looked a bit grey, and his ECG told us why - he was having an acute myocardial infarction.

We rushed about him, trying to explain, but he didn't quite fathom the detail of what we were trying to explain. He understood he was unwell, and that we were trying to help. He trusted us to do what was right, even if he didn't understand the anatomy of what that was.

They were pretty decent actually; low volume, but occasionally complicated patients. Working with one of the Charge Nurses who spent the evening cheering himself in an understated manner... this is difficult to convey with the written word, but try to imagine an ironic cheer: a sort of sarcastic, sottovoce 'hurrah'... but for yourself.

Well I thought it was funny.

Maybe you had to be there.

Satisfaction came, as it so often does, in the form of two sickies. The first, in the late afternoon of life, with chest pain and an ECG that told all we needed to know, its ST segments sagging painfully in the anterior leads, dragging themselves up inferiorly. He was holding it together, just barely, his skin a grey sheen, his breathing ragged, and forced. I called Cardiology down, again, pushing more work their way. We're getting good at this shit now, buffing and polishing, prepping and turfing.

I take pride in being the ED Reg other registrars don't want to work with, the one who brings them work. (Not because they think I smell, I hope...)

The patient, in these situations, finds themselves immersed in vocal turbulence; the chat flows over them, sometimes turning to glance at them; rapid explanations duel with checklists being checked, bloods being drawn, phone calls being made. Mostly it's too much for them, they drift in ad out, an island in the middle of the rush to the balloon.

This one faded out a little too much; he just leaned back and ...stopped. The monitor quieted its annoying, monotonous beeping, and the display moved from regular, friendly complexes to an ugly mess; jagged, irregular lines. Cardiac rhythm by Picasso on acid.

VF.

A brief, very brief pause stretches out before us, as we all see it at the same time. These moments feel like stretching toffee... everything seems to slow down until they... snap, and we're back in the room, and it kicks off.

Praecordial thump, more in hope than anything does nothing, and the bed clatters down, damning any fingers too slow to get out. Sweaty hands begin forcing his chest down, one...two...three... to the tune of Nelly The Elephant, and the pads come out, electricity arcs through his chest cavity, and finds its mark. The monitor coughs, and splutters; when it recovers itself, the rhythm has normalised, and the patient's arms rise, rise ever so slowly, but rise to push us away.

Another of those elastic pauses... then **snap** he's back in the room, and the machine begins to turn again. Minutes later, the whirlwind has gone, blowing out of resus, leaving behind scattered syringe wrappers, dental rolls and ECG dots. ThromboNurse brings us his angio later, and we see his obtuse marginal artery, dammed with clagbefore, flowing freely after, and he's doing well.

A sottovoce hurrah doesn't quite echo through the Department.

The last, probably the worst. A young 'un, barely past the dawning of his day. Mum knows he's unwell, he's been off colour since last night but this morning has found his rash, and brought him to us.

I know he's not well; as they're ushered in, his skin is pale, sallow, with dark ugly circles under his eyes. His sits on Mum's lap, withdrawn, huddling into himself, but still bright enough to look about him. The history is quick to come out, and in between questions I'm asking staff to get me the tools of this particular trade: a cannula, blood bottles, fluid, antibiotics... we need his weight, but he's too weak to stand on the scales. I ask if mum will weigh herslef, then the two together, and she hesitates. I find this slightly absurd, in context, that her son is sick, and still she's worried about us seeing her weight.

I dismiss this as unworthy, she's terrified, she's not thinking straight, and we weigh him with me, instead. The cannula slides in, and he barely flinches. We've all seen the wretched rash by now, obscene reddish-purple blotches under his skin, the only colour left in him by now, and one none of us want.

Fluids and antibiotics follow the line in, and Paeds are down in a flash. My SHOs have watched in silence, not having seen this before, but recognising the gravity of the situation. We talk in hushed whispers afterwards, and I hope this means they never miss a sick kid, that this will serve to be their reference.

I leave him with the Paeds Intensivists, their presence both reassuring, and a stark reminder of how this disease is likely to pan out.

Calling PICU that night was hard to do, I'm not sure I want to hear the news, but he rallied they tell me, is well enough to be bored; he dodged to tube and hasn't needed inotropes. Mum brought him to us soon enough, and he's tough.

Friday, April 17, 2009

While minding your own business, you accidentally learn something you didn't know before. (For example; when looking at a 12 lead ECG, what might normally be treated as an NSTEMI (diffuse ST depression) needs much more agressive intervention when there is ST elevation in lead aVR.

You file that away.

2 days later, you go back to work, and stroll past just such an ECG.

The best thing to do is coolly deploy your knowledge, calmly and professionally.

Tuesday, April 14, 2009

I've just noticed I can 'monetise' my blog... I'm fairly sure that's not a real word, but should I do it? Should we do it? I like the idea of money for (basically) nothing, but since this doesn't cost me anything, do I subject my (few) readers to yet more adverts..?

Not as much as La Belle Fille, who is always sparklingly funny, especially when she talks in her sleep, but quite a lot.

However... it is an Alfa Romeo.

The car looks good.

It sounds good.

It drives well.

But it spends a lot of time broken down.

I don't object to this as much as the fact that there are never any fucking parts. Ever.

Share with me my current car flail.

Had the bastard serviced on the second, when they told me there was a problem with the power steering, and some sort of new tubing was required. It was, unsurprisingly, not in stock, but would be by the following Tuesday.

On Monday afternoon, the expected phone call came; the parts weren't available, much to the dealers's surprise. I opined that this was just what i had expected. Never fear, I was told, they had put me on a 'VIP' list, and the parts would be in situ within 48 hours. I suggested to the dealer, that I was sceptical about this, and was prepared to have a little wager with him, to the effect that the parts would take weeks, if not months, rather than days to come in.

48 hours later, I called back. Much to my surprise, no word had come from Alfa as to the availability, or location of the parts.

I'm still waiting. It'll be 2 weeks on Thursday.

For those of you thinking I deserve the pain for owning an un-necessarily expensive, showy, penis-extension of a car... you're probably right, but you've also probably owned an Alfa

Monday, April 13, 2009

I'm trying to give up the fags, again. (Smokes, or cigarettes, to my North American brethren...). I'm also trying to take up running. I've been trying to run a mile a day since the New Year. (On average) So far, I'm failing... dismally. I think I've managed about 40 miles.

Anyway, to try and keep me interested, I'll check my starting vitals, and chart them weekly... if I can.

Wednesday, April 01, 2009

La Belle Fille and I went out to celebrate a year together. I find this vaguely startling, as my previou tendancies have been mostly directed at avoiding any sort of commitment. Still, it's all about the right person, I guess.

This in itself is perhaps not enormously interesting to the rest of y'all, but I'm reasonably proud of myself, and, more importantly, the dinner had a satisfyingly 'Fawlty Towers' feel to it.

Having slightly flailed our timing, we found ourselves at the restaurant about 15 minutes early. Poking our heads in the door we politley enquired as to whether they were open; a very young looking waiter looked a bit scared, went to check, and told us they were.

It turned out they weren't, but they seated us anyway, while the staff sat down for their dinner. Slightly surreal.

Next, as other, real diners appeared to join us, they were all ushered to some secret downstairs room, for purposes unknown. (presumably having dinner...)

My favourite moment came when young waiter arrived with red wine glasses for us, placing them very carefully, and deliberately next to our existing red wine glasses. He then stood back to admire his handiwork, before noticing.

'Ah', says he, 'you've already got glasses, haven't you?'

'Indeed', say we.

'So... you probably don't need those ones then, do you?'

'Probably not'

He quietly removed them.

We didn't see him again, and I can't help but feel the meal was the poorer for it.

Legal Disclaimer

All the patient details reperesented here are composite. The details of my movements and activities are as accurate as I can make them, but the rest is largely made up. The Shroom's opinions do not represent those of the NHS at large, and should not be taken as a substitute for seeing a proper doctor. Lastly, and for what its worth, all the material herein is copyright The Shroom, and I reserve the right to send large bald men to your place of residence if you reproduce it without permission.